tag:scorpiondoc.silvrback.com,2005:/feedLeslieBoyerMD2017-06-18T02:00:13+03:00tag:scorpiondoc.silvrback.com,2005:Article/324492017-06-18T02:00:13+03:002018-12-26T04:06:11+02:00Venomous Snakes: a Safety Guide for Reptile Keepers<p>From time to time I receive information created by colleagues in the days before online posting was commonplace. Today I was honored to receive a copy of a classic safety guide, provided by author William Altimari. It was first released in 1998 by the Society for the Study of Amphibians and Reptiles, in Herpetological Circular No.26; but most of what it says remains applicable today. With the author&#39;s permission, then, I am placing it here for a new generation of reptile specialists to read at leisure. You can read the entire document by clicking the line after the cover illustration, below.</p>
<p><img alt="Silvrback blog image " src="https://silvrback.s3.amazonaws.com/uploads/4c28ccd1-5cec-49ad-9f3a-f5078bcd9b75/AltimariGuide.jpg" /><br>
<a href="https://silvrback.s3.amazonaws.com/uploads/a3ac5f02-b5f3-4e36-a256-d6a572470893/HC-26-Venomous-Snakes.pdf">Click here to download the PDF</a></p>
LeslieBoyerMDtag:scorpiondoc.silvrback.com,2005:Article/304962017-03-15T22:14:08+02:002018-12-26T04:06:11+02:00Introducing a new series of snakebite training videos<h1 id="what-can-be-done-to-correct-the-antivenom-shortage-in-africa-and-to-bring-prices-down-worldwide">What can be done to correct the antivenom shortage in Africa, and to bring prices down, worldwide?</h1>
<p><img alt="Silvrback blog image " src="https://silvrback.s3.amazonaws.com/uploads/854c4ef4-625c-4ee2-ae12-66fc8dc916ce/Forest%20Cobra.jpg" /><br>
<em>The forest cobra,</em> Naja melanoleuca, <em>is common throughout sub-Saharan west Africa. Emergency medical care after its bite includes prompt administration of antivenom, to prevent nerve paralysis.</em></p>
<p>In <a href="http://scorpiondoc.silvrback.com/the-vicious-circle-of-antivenom-shortage">Part 1 of this article,</a> I described a <a href="http://www.nature.com/nbt/journal/v25/n2/full/nbt0207-173.html">&quot;vicious circle&quot;</a> that is behind the antivenom shortage in sub-Saharan Africa. This is a dangerous situation that causes hundreds of thousands of people to suffer needlessly, or to die, each year. </p>
<p>Correcting the problem will require simultaneous effort by doctors, patients, ministries of health, and drug companies. This is a serious challenge, because African infrastructure for healthcare is incomplete; because there are many different countries involved; and because the various organizations don’t always trust each other. </p>
<p>Individual efforts to increase the sub-Saharan African supply of antivenom, by various doctors and manufacturers, go back many decades. Isolated teams have improved immunization methods, made new products, conducted clinical trials, and donated products to individual hospitals. But for the reasons I outlined in Part 1, individual efforts fail to reverse the vicious circle of shortage – there are too many things to fix, at one time.</p>
<p>Experts in Africa decided about six years ago that it was time to get organized, by establishing an African Society of Venimology (ASV, also known as SAV for Société Africaine de Venimologie). Doing this has not been easy, because Africa is a big, complicated place and it has very few doctors at all, let alone snakebite experts. Some things have improved in recent years, however: mobile phones and laptop computers are becoming common; remote access to medical journals is improving; transportation is moving a little faster. Two hundred doctors and venom scientists, from 22 African countries, have attended SAV-ASV conferences. That’s only about one expert for every 10,000 annual snakebites; but still it’s a major step forward.</p>
<p><img alt="Silvrback blog image " src="https://silvrback.s3.amazonaws.com/uploads/e7ef2563-6cb1-4d5b-85f8-e6cd6183ea82/Wibo%20and%20Agoro.jpg" /><br>
<em>Dr. Sibabe Agoro, a snakebite expert from Togo, examines a boy who is recovering after treatment with a promising new polyvalent antivenom, Inoserp PanAfrica.</em></p>
<p>Considering all the challenges, SAV-ASV has accomplished a lot during those six years. They’ve formed clinical research partnerships and done studies. They’ve given feedback to manufacturers, and in turn some products have been improved to meet Africa’s requirement for heat-stable polyvalent antivenom. They’ve worked with the Ministries of Health of many countries, and in return they are getting better data on snakebite and more help with certification and distribution of high quality products. And they’ve started the process of teaching community doctors and nurses what to do in the event of a snakebite emergency.</p>
<p><img alt="Silvrback blog image " src="https://silvrback.s3.amazonaws.com/uploads/f585791b-cafd-4883-9397-6966587ef5c3/Science%20at%20Noguchi.jpg" /><br>
<em>A young scientist, Georgina Isabella Djameh, studies tropical diseases at the Noguchi Memorial Institute of Medical Research in Accra, Ghana</em></p>
<p>In 2016, the first countries in sub-Saharan Africa stood right on the brink of reversing the vicious circle. From Senegal in the west, through Guinea, Burkina Faso, Ghana, Togo, Benin and Cameroon, to Kenya in the east, doctors reported that more antivenom was being distributed, medical education was happening, and more patients were receiving treatment than before.</p>
<p>Early success is a delicate thing, though. Volunteers get exhausted. Funds run low. Sometimes an epidemic, such as Ebola or Yellow Fever, rages through the community – depleting local resources and taking the lives of doctors and nurses. And that is exactly the situation for the ASV-SAV. They have a long road ahead.</p>
<p>I wanted to help, but wasn’t sure how one more venom doctor could make much of a difference. Then someone pointed out that we Americans have something important that is extremely scarce in sub-Saharan Africa: ready access to media technology and to experts who know how to use it well. Perhaps I could help by creating some training materials for doctors and nurses, so that my overworked colleagues in Africa could be more efficient in getting the word out?</p>
<p>As luck would have it, I participated as a subject in an excellent documentary video recently, <a href="http://thevenominterviews.com/">The Venom Interviews</a>, produced by a nerd-on-a-mission named Ray Morgan. On impulse, I contacted Ray. If I could figure out the logistics, would he be willing to help create a multi-part series of brief videos on diagnosis and treatment of snakebite? Primarily for distribution on thumb-drives? Mainly for rural nurses, by the way, in sub-Saharan Africa? Oh yes, and primarily in French? </p>
<p>Ray signed on without time to take a breath. Before I even got to the language part, actually.</p>
<p>It took several months to get Yellow Fever immunizations, renew passports, apply for visas, and arrange an itinerary that would work for two dozen people. Dr. Jean-Philippe Chippaux guided content for the script and logistics for the road; Dr. “Boss” Bosompem helped with arrangements in Ghana; Dr. Achille Massougbodji made special arrangements in Benin; Inosan Biopharma provided partial support plus open access to their manufacturing facility; Dr. Giambattista Priuli agreed to provide space and food for a meeting of experts in the Hôpital Saint Jean de Dieu; Drs. Alejandro and Andrés Alagón put us up at their ranch in Mexico and arranged for a plasma production facility tour; Nathaniel Frank wrangled snakes in a specially-built habitat; and several dozen other doctors, scientists, students and specialists agreed to join forces for the effort.</p>
<p>That was in October of 2016, and I for one have learned a LOT in the intervening months -- there is no greater pleasure for a doctor like me, than learning up close from the world’s experts in a complicated part of my field. We estimate that editing will take about a year to complete, and that we’ll be producing about ten short segments in all. Today, however, I’m delighted to say that a preview/trailer module is complete, and that Ray and I have uploaded it to Vimeo for anyone in the world to watch. I hope that you like it, because we need people around the world to follow along, to learn, and perhaps even to help us out in the future. If you agree, then please share and subscribe to the Vimeo channel in <a href="https://vimeo.com/channels/venimologie">French</a> or <a href="https://vimeo.com/channels/venimology">English</a> or <a href="https://vimeo.com/channels/venenologia">Spanish,</a> or use SAV-ASV’s new “Venimologie” handle on <a href="https://www.facebook.com/groups/venimologie/">FaceBook</a> or <a href="">Twitter,</a> to receive word when future training modules are released. </p>
<iframe src="https://player.vimeo.com/video/202410166?title=0&amp;byline=0&amp;portrait=0" width="640" height="360" frameborder="0" webkitallowfullscreen="" mozallowfullscreen="" allowfullscreen=""></iframe>
LeslieBoyerMDtag:scorpiondoc.silvrback.com,2005:Article/304652017-03-11T21:38:12+02:002018-12-26T04:06:11+02:00The Vicious Circle of Antivenom Shortage<h1 id="what-is-going-on-with-the-shortage-of-antivenom-in-africa">What is going on with the shortage of antivenom in Africa?</h1>
<p><img alt="Silvrback blog image " src="https://silvrback.s3.amazonaws.com/uploads/fd811435-131d-4f32-9f66-b38e17805cb1/FavAfrique.jpg" /><br>
<em>Discontinuation of Sanofi Pasteur&#39;s Fav-Afrique brought attention to a longstanding shortage of antivenom in sub-Saharan Africa.</em></p>
<p>Followers of this blog may rightly wonder what happened, after the <a href="http://scorpiondoc.silvrback.com/giving-african-doctors-a-voice">“Giving African Doctors a Voice”</a> guest blog in May 2016. Millions are bitten by venomous snakes each year, and hundreds of thousands who lack access to good antivenom die or suffer awful injuries. The African Society of Venimology, which consists of doctors and scientists close to the action, put out word that they are facing a serious problem, and that <a href="http://www.sav-asv.org/download/news/ASV-Press-Release-05-31-16-final.pdf">they’re dealing with it whether or not the rest of us get involved.</a> It’s time that I wrote again, to explain how I got drawn into things.</p>
<p>The side conference at the 2016 World Health Assembly, which had been conceived by all concerned as an opportunity to raise awareness of snakebite, was in that sense a success. The story was carried independently by <a href="https://www.vice.com/en_us/article/once-bitten-v23n2">Vice News</a> and by <a href="http://www.nature.com/news/vipers-mambas-and-taipans-the-escalating-health-crisis-over-snakebites-1.20495">Nature</a>, and about two dozen antivenom manufacturers and researchers around the world posted their distinct points of view on how to address the <a href="http://www.businessinsider.com/antivenom-snakebite-snake-venom-antidote-shortage-2016-9">shortage of antivenom in Africa and beyond.</a> This is clearly an issue whose time has come.</p>
<p>Meanwhile, here in the USA, toxinologists and reptile specialists were facing a related problem, namely that <a href="https://scorpiondoc.silvrback.com/antivenom-in-the-usa">our system for providing antivenom</a> to treat <a href="https://scorpiondoc.silvrback.com/top-ten-exotic-snakebites-in-the-usa">non-native snakebite</a> depends heavily on experimental or “investigational” antivenoms, most of which are <a href="https://scorpiondoc.silvrback.com/how-prepared-is-the-us-healthcare-system-to-treat-non-native-snakebite">available only from zoos</a>, and that our <a href="https://www.washingtonpost.com/news/wonk/wp/2015/09/09/the-crazy-reason-it-costs-14000-to-treat-a-snakebite-with-14-medicine/">licensed antivenom products are significantly more expensive than elsewhere in the world</a>. Pricing comparisons were made with the <a href="https://www.scientificamerican.com/article/martin-shkreli-who-raised-drug-prices-from-13-50-to-750-arrested-in-securities-fraud-probe/">Martin Shkreli scandal</a>, and with the <a href="http://fortune.com/2016/09/27/mylan-epipen-heather-bresch/">rising price of the Epi-Pen.</a> I’ve been caught up in the US side of things because of my organizing role with the <a href="http://app1.unmc.edu/publicaffairs/todaysite/sitefiles/today_full.cfm?match=2906">Association of Zoos and Aquariums&#39; Antivenom Index,</a> and with a <a href="https://clinicaltrials.gov/ct2/show/NCT01337245">clinical trial of coral snake antivenom,</a> and with some collaborations involving the US FDA.</p>
<p>When calls from the press came into my office last summer, I found myself having to ask, “WHICH antivenom crisis?” to distinguish Africa from the USA. Each time this happened, I felt important very briefly; then I felt very stupid. This was, of course, because good reporters immediately wanted to know how the two issues were connected; and I simply wasn’t enough of an expert on international economics to give them a proper answer.</p>
<p>Well, time passed. And one day I found myself with an international group of people, no one of whom knew the whole answer, either – but among us, maybe we could figure it out. We agreed on some very basic things, particularly related to Africa:</p>
<ul>
<li>A lot of people are bitten by snakes, and many of them need antivenom to survive.</li>
<li>Some manufacturers know how to make good antivenom, at an affordable price per dose if they make a lot of it at one time.</li>
<li>Many doctors are very good at treating snakebitten patients, if only they have enough of the right antivenom.</li>
<li>And yet, the world does not have enough treatment for everybody that needs it,most doctors don’t know how to use it, and the per-dose cost to make antivenom in low quantities is high.</li>
</ul>
<h2 id="it-seemed-so-obvious-from-the-outside-pharma-companies-should-simply-make-a-whole-lot-of-good-antivenom-and-doctors-should-use-it-but…-that-wasn’t-happening-why-not">It seemed so obvious, from the outside: pharma companies should simply make a whole lot of good antivenom, and doctors should use it. But… that wasn’t happening. Why not?</h2>
<p>We talked about how one thing leads to another, in what colleagues have called a <a href="http://www.nature.com/nbt/journal/v25/n2/full/nbt0207-173.html">vicious circle</a>: a shortage means that there is no antivenom, or that low-quality products prevail. Lack of good medications means that doctors cannot provide good care. Poor care means that patients seek alternatives instead of going to the hospital. A small number of patients at the hospital means the market for antivenom sales is low, which means that quality manufacturers lose interest. And back to the beginning again.</p>
<p>The worst thing about vicious circles is this: if even one part of the system is broken, all the other parts fail. <em>The only way to fix them is to work on everything at once.</em></p>
<ul>
<li>At least one manufacturer needs to make a whole lot of good antivenom.</li>
<li>Somebody needs to certify that it works and is safe, so fake stuff doesn’t price the good stuff out of the market.</li>
<li>Somebody needs to buy it and get it into the hospitals.</li>
<li>More doctors and nurses need to learn how to treat patients properly, and how to obtain the higher quality medicines.</li>
<li>Everybody with a snakebite needs to go to the hospital for care.</li>
</ul>
<p>In Mexico, they used to have a problem like Africa’s, but they solved it by attacking every issue simultaneously. Product improvements were put in place simultaneously with government outreach and massive education efforts. Over a decade or two at the end of the last century, Mexico became both a major producer and a major consumer of good antivenom. As a result, mortality from venom injury fell dramatically. Africa now needs to do the same as Mexico once did.</p>
<p>For me, a doctor in the USA, there is one more thing to fix, but it falls outside of the circle because our infrastructure allows for high prices but bars the sale of most world products:</p>
<ul>
<li>The USA needs a legal and affordable way to obtain successful world antivenoms, for the rare cases where our citizens are bitten by snakes from other places.</li>
</ul>
<p>We have some <a href="http://www.smithsonianmag.com/smart-news/why-single-vial-antivenom-can-cost-14000-180956564/">infrastructure issues of our own to confront</a>, to solve this. It’s apparent, however, that the USA must come last in this process. The quality will not go up, nor the shortage end, nor the price come down, simply to satisfy our tiny market. We must depend on places like Africa and Mexico to save us, this time.</p>
<p>Next week, I’ll tell you what the group decided to do.</p>
LeslieBoyerMD